Facial Asymmetry

ORTHODONTICS

1. DEPARTMENT OF ORTHODONTICS AND DENTOFACIAL ORTHOPAEDICS SEMINAR PRESENTATION Presented by: Dr. Deeksha Bhanotia MDS second year Guided by: Dr. Mridula Trehan Professor and Head FACIAL ASYMMETRY 1

2. Introduction E tiology of facial asymmetry - Genetic E nvironmental C lassificat i on of facial asymmetry Dental Skeletal Functional muscular CONTENTS 2

3. D iag no s is of facia l asy m m e try Medi c al hi story De ntal eval u a tion P h oto gr aph for facial eval u a tion Radiographs: La t er a l cephalograms Pan o r a mic eval u a tio n s PA vi ews TMJ imag i ng M anagem e nt of facial asymmetry 3

4. I n t r o d u c t i on Each p ers o n sha r es many c h aracte r isti cs with the rest o f the pop u lat i on . Variation - provides his or her own identity. S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 A u g ;1 9 ( 3 ) : 395 - 422 4

5. N o human Face – symme tric Goal of orthodontic treatment - create a balanced n harmo nious facial propo r tion S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 A u g ;1 9 ( 3 ) : 395 - 422 5

6. Symmetry : “ Equality or correspondence in the form of parts distributed around a centre or an axis, at the two extremes or poles, or on the two opposite sides of the bod y . ” (Steadman’s Medical dictionary) Clinically, symmetry means balance, where as as y mmetry means imbalance . Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 I n t r o d u c t i on 6

7. Facial Asy m m e try – “Imbalances that occur between homologous parts of the face affecting the proportion of these parts to one another with regard to size, form, and position on opposite sides of a plane, line or point.” The division of normal from the abnormal – clinician’s sense of balance and patient’s perception o f imba lance Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 I n t r o d u c t i on 7

8. Rig h t & le f t facial as y mm e tries T ooth siz e Cle f t lip Cheong YW, Lo LJ. Facial Asymmetry: Etiology, Evaluation, and Management. Chang Gung Med J 2011;34:341-51 I n t r o d u c t i on 8

9. Asymmetry o f the upper fac e - 5 % , M idd l e third - 36 % Lower third /deviation of the chin-75% I n t r o d u c t i on 9 Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98

10. Among o r thod o ntic patients Mandibular midline devia t i o n 62% Ma x il l a r y mi d li n e devia t ion 39% Mo l ar classific at ion asymmet r y 22% Maxillary oc c lusal asym m et r y 20% Mandibular o c c l usal asym m et r y 18% Facial asym m et r y 6% Chin devia t i o n 4% N o se devia t i o n 3% I n t r o d u c t i on Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 10

11. Woo (1931) – Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 C ranial bones – asymetric . R ig ht f r ontal, temporal & parital - larger . F acial bone s - left zygoma and maxi l l a – larger . 11

12. Pec k - Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 Less asymmetry and more dimensional stability as the cranium is appr o ached . Te n d ency tow a rd right - side - not s t atistically significant. 12

13. Vig and Hewitt 1975: Cranial base - larger left side Mandi bular region - larger left side Maxil l ary region - larger right side Dentoalveolar symmetry - compensatory change. Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 13

14. Sh arad Sh ah & M . R . Jo s hi – 1978 : Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 Pleasing & apparently symmetrical faces do exhibit skele tal asymmetr y . Soft tis s ue o f the fa ce att e m pts to m i nim ize t h e unde r lyin g skele tal asymmetr y . 14

15. Ac c o r di n g to Wool – “Facial asymmetry is due to asymmetric development of the brain, with dominance of the right hemisphere possibly influencing an asymmetric muscul a r habit, s u ch as unilate ral masticat i o n . ” Etiology 15

16. Etiology Gene tic Environmental Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 E t i o l o g y 16

17. 1 . Clefts o f li p o r palate – Facial deformity with associated collapse of maxillary dental arch. Left sided : right sided – 2 : 1 . Gen e ti c Etiology Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 17

18. Environmental 1. I n traut e r i n e pressur e Parturition - Molding of parietal & facial bones fro m pre s s ures – fa c ial as y mmetr y . Tran s ient ef f ects Restoration - within a few weeks to several month s . E t i o l o g y Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 18

19. 2. Trauma & infec t i o n – Trauma & infecti on with i n TM joi n t Ankylosis Untreated f r actu r es of cond y le. – c o mpensa t o r y growth leading to o v erg r owth of cond y le on af f ected sid e . E t i o l o g y Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 19

20. 1. Asymm e t r y accor ding to L u ndstorm in 19 6 1 Quantitative asymmetry - dif f erenc e s in the number Qualitative asymmetry - di f f e rence in siz e , locat ion of the teeth, position of the a r ches. Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 C l a s s if i c a t ion 20

21. Dental asymmetry Skel etal as y mmetry Musc u lar asymmetry Functional asymmetry 3. Structural Classification of Dentofacial Asymmetry C l a s s if i c a t ion Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 21

22. 1. Dent al asy mm etrie s - Conge nita l ly missing to o th o r teeth S h ape and si z e alt e ration of the te e th S h ape of dental arches . M i dl i ne deviat i ons C l a s s if i c a t ion Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 22

23. 2. Skelet a l asym me tries – Involve o n e o r mo r e skeletal st r u c tu r es on o ne side of the face . Skeletal asymmetry He mi mand i b ular e l on g a t i o n He mi mand i b ular h yp erp las i a Body e l on g a t i on C o nd y l ar / ramus el o n g a t i on Obwegeser (1986) C l a s s if i c a t ion 23

24. Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 Muscular asymmetry – e. g. hemifacial atrophy Muscle size discrepancy – e. g. masseter hypertrophy. Abno r mal muscle f u nction . C l a s s if i c a t ion 24

25. U v cheong 4. F u n ctional asym me tries – Occlu s al inte r f erences. Const r icte d maxi l lary a rch TM joint derangement - anteriorly displaced disc without r eduction – midline shift due to interferences in mandibular tran s lat i on on aff ected side . C l a s s if i c a t ion Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 25

26. Medi c al hi story De ntal eval u a tion P h oto gr aph for facial eval u a tion D. Radiographs: La t er a l cephalograms Pan o r a mic eval u a tio n s PA vi ews TMJ imag i ng Essential patient evaluations for facial asymmetry Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 Diagnosis 26

27. A. Clinical examination Asymmetry in the vertical, antero -posterior or lateral dimension Diagnosis Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 27

28. B. Dental evaluation Eval uatio n o f denta l m i dl i nes . ￭ Mou th open ￭ In i tial contact ￭ Centric occlusion ￭ Difference between true asymmetry & f u nction a l as y mmetry needs t o b e as s esse d . Diagnosis Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 28

29. Ve r tica l occlu s a l evaluation . ￭ Canted occlu s al plane ￭ Can be obse r ved by asking t he patient to bite on tongue blade & determine its relation to inter- p u pil l ary plane . Diagnosis Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 29

30. Transverse & anteroposterior occlusal evaluations. ￭ Careful diagnosis of unilateral posterior crossbite to evaluate if it is skeletal, dental or functional. ￭ Deviation o f mandible fro m CR t o CO ￭ Occlu s al view – intra - arch analysis Diagnosis 30 Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98

31. C. Photograph for facial evaluation Diagnosis Proffit W. Contemporary Orthodontics. 3rd Ed 31

32. Submental view and Supracranial view Patient’s head - extended to 45 . Use f ul to assess symme try Asymmetries of anterior cranial vault, orbital areas and cheeks and Nasal deformities Diagnosis Proffit W. Contemporary Orthodontics. 3rd Ed 32

33. The p o siti o ns nas a l b ridge, na s al tip, filtrum, chin point are assessed with dental landmarks i.e. upper incisor midline, lower incisor midl ine Proffit W. Contemporary Orthodontics. 3rd Ed Diagnosis 33

34. Rule of fifth describe the ideal transverse relationship o f the fac e . Diagnosis Proffit W. Contemporary Orthodontics. 3rd Ed 34

35. A we l l pr o po r tioned f ace is vertical l y divid e d in to equal thirds Subnasale to upper lip inferior - lower l i p s u p erior to s o ft tiss u e menton - 1/3 rd and 2/ 3 r d . Diagnosis Proffit W. Contemporary Orthodontics. 3rd Ed 35

36. Deficient or excess Proffit W. Contemporary Orthodontics. 3rd Ed Total width is compared with total face hei ght ( r atio) Zy - z y / T r - G n x 100 Diagnosis 36

37. 1. Late ral c e pha l o gra m - Used to assess A-P and vertical relationships Lim ite d value in diagnosing asymmetries Ramal height, mandibular length & gonial angle. Radi o graph s Diagnosis Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 37

38. 2. Panoramic radiograph – P r esence of gr o ss path o logy, missing or s u pern u merary teet h . Shape of mand i bular r amus & condyles. Diagnosis Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 38

39. 3. Po s te r o - an te r i or pr o jec tion – Valuable to o l Right & left structures are located at relatively equal distances f r om the film & x - ray s o u r ce. Can be taken in centric occlu s ion & mo u th open position Diagnosis Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 39

40. GRUMMONS ANALYS I S - 1987. Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod 1987;21:448-65. Diagnosis 40

41. 1 . Mandib u la r Mo r ph o log y Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod 1987;21:448-65. Left and r ig ht t r iang les – Co- - Ag-Me. These are split by the AN S - Me l i ne and compa r ed. Diagnosis 41

42. 2 . V olumetri c Comparison Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod 1987;21:448-65. intersecti o n with a pe r pendicular f r om Co to MS R . Two " v o lumes" are calculated - C o - Ag - Me and the inte rsection point Diagnosis 42

43. Pe r pendicula r s t o MSR f r om J and Ag Connecting l i nes f r om Cg to J and Ag. Produces two pairs of triangles, each pair bisected by MS R. If pe r fect symmetry - fou r triangl es become two, J-Cg-J and Ag-Cg-Ag. 3. Maxillo-Mandibular Comparison of Asymmetry - Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod 1987;21:448-65. Diagnosis 43

44. 4 . Linea r Asymmet ries - Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod 1987;21:448-65. Linear distance is measu r ed f r om MSR to C o , N C, J, Ag, a n d Me. Diagnosis 44

45. 5 . Maxil l o -Mandib u la r Re l ation - Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod 1987;21:448-65. From buccal cus ps of the upper first molars to the J perpendiculars. Midl ine as y mmetries o f the u p per and lower inc i s o rs and M e - MSR are also p r o v ided. Diagnosis 45

46. C g - Me li ne - di v is i o n s at A N S, A 1, and B1. T h e fol l ow i ng r a tios a r e calculate d : ￭ Upper facial ratio — Cg-ANS/Cg-Me ￭ Lower facial r a ti o — AN S - Me / Cg - Me ￭ Maxillary ratio — ANS-A1/ANS-Me ￭ To t al ma x il l a r y r a ti o — AN S - A1/ C g - Me ￭ Mandibular r a ti o — B 1 - Me / A N S -Me ￭ T o t a l mandibular r a ti o — B 1 - Me / Cg - Me ￭ Maxillo-mandibular ratio — ANS-A1/B1-Me Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod 1987;21:448-65. 6. Frontal Vertical Proportions - Diagnosis 46

47. Three separate acetate tracings A. 1 st acetate sheet - the o r bital rims, py r ifo r m apert u re, maxi l lary and mandibular incisors, and the midpoint of the symphysis. most s u per f ic i al aspects of the face Grayson’s analysis - in 1983. Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry. Am J Orthod 1983;84:217-24. Diagnosis 47

48. B . 2 nd acetate sheet - greater and lesser win gs of the sphenoid, zygomatic arch, co ron o id process, the ma x i l lary and mandi bular fir s t permanent molars, the body of the mandi ble, and the mental foramina Represent a deeper coronal plane. Diagnosis Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry. Am J Orthod 1983;84:217-24. 48

49. C. 3 r d acetate tr a cin g , u pper s u rf ace of the petr o us po r tion of the temporal b o ne, mandib u lar c o ndyles, r am u s, gonial angl e, and the mastoid pr o cesses Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry. Am J Orthod 1983;84:217-24. Diagnosis 49

50. Mid l ine f o r each view : Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry. Am J Orthod 1983;84:217-24. In the A pl a ne – Centrum of each orbit is located, - point Mce halfway between them is mar k e d . The most lateral point on each pyriform - halfway - poin t Mp . maxil l ary and inc i s o r s - Mi , Gnathion - Mg t h e mandi b ular central - connect Diagnosis 50

51. B plane - Si G reater an d les s er Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry. Am J Orthod 1983;84:217-24. wings o f the sphenoid - m i dpoint Msi zygomatic arches - Mz co ron o id pr o cesses - Mc left an d right zygomas - Mx Left and right mental f o ramina - Mf Diagnosis 51

52. Plane C Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry. Am J Orthod 1983;84:217-24. Heads of the cond y les - Md Mastoid pr o cesses - Mm G onions - Mg o , Diagnosis 52

53. Superimpose mid l ine of A, B, and C plane s - warping with i n the cranio f acial skele ton. The midline deviate laterally as passing f r om plane C, thr o ugh plane B, to plane A In patie nt s with facial asym me try - posterior and middle cranial structures appear less severely affected Diagnosis Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry. Am J Orthod 1983;84:217-24. 53

54. Plagiocephaly Cleft in g c o nditi o ns Hemifacial hyper p lasia Hem i facial a t rophy Hemifacial microso mia Con dylar h y pe r plasia Trauma * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin N o rt h A m. 2007 A u g ;19 ( 3) : 395 - 422 Skele tal Asy mm e tries 54

55. Flat head sy n d r o m e A s ym met r i c al distor t i on o f the skull . Two m ain c a us es : def o rmatio n al plag i ocep h aly ( D P ) a nd craniosynostotic plagiocephaly (CP). D P - cranial m o ldi n g - he l met ther a py Plagiocephaly * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 55

56. Craniosynostosis - a premature fusion of cranial sutures – reconstr u cti o n su r geries Eleva t ed int r ac r anial p r essu r e ( I C P ) Without increased ICP- delay reconstruction until 12 -24 months of age. Infants with increased ICP - between the ages of 2 and 9 months * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 Plagioc e p h aly 56

57. Plagioc e p h aly * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 Case report 57

58. Development of a fibrous band in the sternocleidomastoid muscle Uni l a t er a l tilt of the ne c k Torticollis * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 58

59. My oto my and l en g theni ng of the SCM musc l e . E x c i si o n of the entire SCM m uscle and i ts band f r om its orig i n to its insertion. * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 Torticollis 59

60. Unilateral clefts- can cause facial asymmetries - most common cause of congenital asymmetry of the craniomaxillofacial skeleton. D ep e n ds on the l o cation and extent o f the c l eft . Ev en in the repaired sta t e Cleft lip and palate * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 60

61. Leads to facial asymmetry that grows throughout childhood. Both soft tissue and hard tissue structures can be affected, in c l u d in g tee t h Hemifacial hyperplasia * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 61

62. Main aim is - follow up until the growth has stopped . Any f u nctio n al c o rr ection s can be pe rfor med. H em ifa c ial h y perplasia Jagtap RR, Deshpande GS. Gingival enlargement in partial hemifacial hyperplasia. Journal of Indian Society of Periodontology.2014:18(6):772-775 62

63. Pa r r y - R o mberg sy n d r o m e . Progressive condition - severe atrophy of all of the hard and s oft tissues of on e side of the face Sil i c o ne and fat i nj ecti o ns, h y d r oxyapa t ite all o plastic impl ants to m ask the defec t. * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 Hemifacial atrophy 63

64. The patient was treated with a u toge n ous fa t gr a f t in g Under general anesthesia - li p o s u cti o n - 50 mL o f fa t i nj e cted the pa t ie n t’s a t rophic he m ifac e . H em ifa c ial atrop hy * J ú lio C é sar Garcia de Alencar et al. Autologous fat transplantation for the treatment of progressive hemifacial atrophy (Parry-Romberg syndrome: case report and review of medical literatute) . An Bras Dermatol. 2011;86(4Supl1):S85-8. 64

65. Treatment strategy depends each patient’s age, physical examinatio n , photog r a phs, r a dio gr a phs, m o un t ed m o dels. Treatments vary from the use of functional dentoalveolar or t ho p a edic a p p lianc es t o t otal TMJ r ec o nst r uc t io n. Hemifacial microsomia * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 65

66. T r eat m en t of hemifacial microsomia Functional ap p li anc e s Surgical intervention Or t h o gnathic surgeries Distraction osteogenesis Soft tissue manage m ent * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 H e mifac i al mic r o s o mia 66

67. G r owth m o dification with Hybrid f u n c tio n al appliance Bite block on normal side to prevent over eruption Occlusal clearance o n the af f e c ted side * El-Bialy et al. Nonsurgical treatment of hemifacial microsomia by therapeutic ultrasound and hybrid functional appliance. Open Access Journal of C li ni cal T r ials 2010 : 2 : 2 9 - 37 H e mifac i al mic r o s o mia Functional appl i ances 67

68. Bi - jaw or t ho gna t hic su rgery - bone g r af t ing may be r equired Le Fort I osteotomy – canted occlusal plane. Co nc o mitant mand i bular osteotomies : - B i l a t e r al sagi t t al spl it ramu s ost e o t omies or; - B il at e ral ve r t i cal ramus oste o tomi e s o r ; -ipsilateral vertical ramus osteotomy with contralateral sagittal split osteotomy Genioplasty * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 H e mifac i al mic r o s o mia Surgical inte r v enti on 68

69. H e mifac i al mic r o s o mia * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 69

70. H e mifac i al mic r o s o mia * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 70

71. H e mifac i al mic r o s o mia * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 71

72. H e mifac i al mic r o s o mia * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 72

73. New bone formation between the surfaces of bone segments that are gradually separated by incremental traction A callus forms - traction - callus tissues are stretched inducing the new bone forma t i on Distr action os teogenes is *Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesi s temporary anchorage devices, and orthodontics, Am J Orthod Dentofacial Orthop 2012;142:115-2 H e mifac i al mic r o s o mia 73

74. *Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis, temporary anchorage devices, and orthodontics, Am J Orthod Dentofacial Orthop 2012;142:115-28 H e mifac i al mic r o s o mia 74

75. H e mifac i al mic r o s o mia *Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis, temporary anchorage devices, and orthodontics, Am J Or thod Dento f acial Or thop 2012 ; 142 : 115 - 28 75

76. Predi s t r a ction Phase Dis t r a ction Phase Post d i s t r a ction Phase E dg ew i se brac k ets ( 0.022 in) – Al i g nment and leveli n g . 0.020 X0.02 5 - in stai nless steel A horizontal ramus osteotomy - left, at the level of the occlusal plane An angle o steot o my – right Advancement 18 mm along the ramus on the left and 6 mm on the right. Distraction at a rate of 0.5 mm twice per day for 18 days E r u ptio n o f the ipsi lat eral maxi ll ary teet h. biteplane - reduced under the maxillary left second molar to allow its g radual er u ptio n first and second premo lars Vertical traction was flanked by a mandibular miniscrew and a hook soldered between the left canine and lateral incisor *Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis, temporary anchorage devices, and orthodontics, Am J Or thod Dento f acial Or thop 2012 ; 142 : 115 - 28 H e mifac i al mic r o s o mia 76

77. H e mifac i al mic r o s o mia *Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis, temporary anchorage devices, and orthodontics, Am J Orthod Dentofacial Orthop 2012;142:115-28 77

78. H e mifac i al mic r o s o mia *Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis, temporary anchorage devices, and orthodontics, Am J Orthod Dentofacial Orthop 2012;142:115-28 78

79. H e mifac i al mic r o s o mia *Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis, temporary anchorage devices, and orthodontics, Am J Orthod Dentofacial Orthop 2012;142:115-28 79

80. Asymmetric deficiency secondary to an early fracture of the Con dylar p r o c ess 1. Acute management of condyle fracture in children - Immobilization of the jaw for 7 to 14 days - E x ercis e s to i mprove mandibular r a nge o f m o ve m ent Trauma 80

81. Emplo y a c o stoc h o ndr a l gr a ft * S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 T r a u ma 2 . Management of Post traumatic asymmetry: Early surgery to guide condyle for subsequent growth Use local tissue, such as stump of the remaining ramus or 81 3. Reconstruction of the TMJ in growing patient

82. Asymmetric extraction sequences and asymmetric mechanics e.g class III elastics one side and class II elastics on the other with oblique elastics anteriorly. Composite build up or prosthodontic restoration may be indicated with pronounced tooth irregularities. Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 Dental Asymmetries 82

83. *Jung SK, Kim TW. Treatment of unilateral posterior crossbite with facial asymmetry in a female patient with transverse discrepancyAm J Orthod Dentofacial Orthop 2015;148:154-64 83

84. *Jung SK, Kim TW. Treatment of unilateral posterior crossbite with facial asymmetry in a female patient with transverse discrepancyAm J Orthod Dentofacial Orthop 2015;148:154-64 84

85. *Jung SK, Kim TW. Treatment of unilateral posterior crossbite with facial asymmetry in a female patient with transverse discrepancyAm J Orthod Dentofacial Orthop 2015;148:154-64 85

86. *Jung SK, Kim TW. Treatment of unilateral posterior crossbite with facial asymmetry in a female patient with transverse discrepancyAm J Orthod Dentofacial Orthop 2015;148:154-64 86

87. Midl in e c o ordination and relative sy m met r y a r e basic to an ap p reciation of facial ha r m o ny and balan c e. Lewis espo uses a se t of q u esti o ns : – (1) What has caused the midline deviation? – (2) How does the deviation affect the occlusion? – (3) Is it nec essa r y t o cor r ect it? The midline shift *Jerrold L, Lowenstein LJ, The midline: Diagnosis and treatment. Am J Orthod Dentofac Orthop 1990;97:453-62 87

88. Angle: tandem anterior diagonal elastic Class III elastic OR c l ass II e l astics The midl i n e s h if t *Jerrold L, Lowenstein LJ, The midline: Diagnosis and treatment. Am J Orthod Dentofac Orthop 1990;97:453-62 88

89. St r ang and T h o m pson : D o u ble vertical spring lo o p a u xiliary adjusted for the mass m o v e m e n t o f the four i n c i s o r teeth t o the l eft. Midl in e - to be s hi f ted to l ef t . Closing loop - as close to the left canine as pos s ibl e. On activatio n - the arch r ebounds t o its preactiv ated pos i tio n , it wi l l carr y the four i n c i s o rs with it to the l e f t . The midl i n e s h if t *Jerrold L, Lowenstein LJ, The midline: Diagnosis and treatment. Am J Orthod Dentofac Orthop 1990;97:453-62 89

90. 90 Evaluation of the path of closure from postural rest to habitual occlusion in the transverse plane . Clinical examination of transverse functional relationships is easy to perform. If consists of observing the behavior of the mandibular midline as the teeth are brought together from rest position to habitual occlusion. Two types of crossbite cases with lateral shifting of the mandibular midline can be differentiated. LATEROGNATHY AND LATERO-OCCLUSION Graber T, Rakoshi T, Petrovic A. Dentofacial Orthopaedics with Functional Appliance. 2nd ed.

91. 91 The first is a crossbite in which the midline shift of the mandible can be observed only in the occlusal position. In postural rest the midlines are coincident and well centered . The mandible slides laterally from rest position into a crossbite in occlusion. This is called a laterocclusion , or pseudo- crossbite , and is caused by tooth guidance. Treatment requires eliminating the disturbance in the intercuspation . This often is done by widening the narrowed maxillary arch, thus improving function. Graber T, Rakoshi T, Petrovic A. Dentofacial Orthopaedics with Functional Appliance. 2nd ed.

92. 92 The second is a crossbite in which the midline shift is present in both occlusal and postural rest positions (e.g., a true asymmetric facial skeleton). This is some times referred to as laterognathy . Successful functional appliance treatment is not possible in such cases; in severe cases, surgery is the only Graber T, Rakoshi T, Petrovic A. Dentofacial Orthopaedics with Functional Appliance. 2nd ed.

93. 93

94. Symmetry - quintessential ingredient in facial aesthetics In spite of being highly prevalent in the overall population, facial asymmetry is scarcely addressed in dental literature . In the management of asymmetries – appropriate treatment plan, force sy s tem, and the ap p li ance is sel ected . 94

95. Re fer ences S á ndor GK, McGuire TP, Ylikontiola LP, Serlo WS, Pirttiniemi PM. Management of facial asymmetry. Oral Maxillofac Surg Clin North Am. 2007 Aug;19(3):395-422 Jagtap RR, Deshpande GS. Gingival enlargement in partial hemifacial hyperplasia. Journal of Indian Society of Periodontology.2014:18(6):772-775 J ú lio C é sar Garcia de Alencar et al. Autologous fat transplantation for the treatment of progressive hemifacial atrophy (Parry-Romberg syndrome: case report and review of medical literatute) . An Bras Dermatol. 2011;86(4Supl1):S85-8. El-Bialy et al. Nonsurgical treatment of hemifacial microsomia by therapeutic ultrasound and hybrid functional appliance. Open Access Journal of Clinical Trials 2010:2:29-37 Amm EA. Three-year follow-up of a patient with hemifacial microsomia treated with distraction osteogenesis, temporary anchorage devices, and orthodontics, Am J Orthod Dentofacial Orthop 2012;142:115-28 Jung SK, Kim TW. Treatment of unilateral posterior crossbite with facial asymmetry in a female patient with transverse discrepancy. Am J Orthod Dentofacial Orthop 2015;148:154-64 95

96. Grayson BH, McCarthy JG, Bookstein F. Analysis of craniofacial asymmetry by multiplane cephalometry . Am J Orthod 1983;84:217-24 Grummons DC, Kappeyne Van De Coppello MA. A frontal asymmetry analysis. J Clin Orthod 1987;21:448-65 Graber T, Rakoshi T, Petrovic A. Dentofacial Orthopaedics with Functional Appliance. 2nd ed. Jerrold L, Lowenstein LJ, The midline: Diagnosis and treatment. Am J Orthod Dentofac Orthop 1990;97:453-62 Palacios P, Uribe F, Nanda R. Correction of an Asymmetrical Class II Malocclusion Using Predictable Force Sy s tem s . J Cl i n O rt h o d . 2007 : 12 ( 4 ) : 21 1 - 16 Bishra SE, Burky PS, Kharaouf JG Dental and facial asymmetries: A review. Angle Orthod 1994;64(2):89-98 10 . Cong YW, Lo LJ. Facial Asymmetry: Etiology , Evaluation, and Management. Chang Gung Med J 2011;34:341-51 11. Proffit W. Contemporary Orthodontics. 3rd Ed 96

97. 97